seth christian md, mba department of anesthesiology tulane university hospital and clinics
TRANSCRIPT
![Page 1: Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics](https://reader036.vdocuments.mx/reader036/viewer/2022062515/56649cdc5503460f949a6d85/html5/thumbnails/1.jpg)
Seth Christian MD, MBADepartment of AnesthesiologyTulane University Hospital and
Clinics
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PAT
Online
Urgent Emergen
t
Admission
Additional Testing
OPS
Info
Info
Holding
Surgery Clinic
Inpatient
Surgery Clinic
Surgery Clinic
Surgery Clinic
Surgery Clinic
PreopNo
Surgery
Recovery ICUWard
Discharge
Regional
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PAT
Online
Urgent Emergen
t
Admission
Additional Testing
OPS
Info
Info
Holding
Surgery Clinic
Inpatient
Surgery Clinic
Surgery Clinic
Surgery Clinic
Surgery Clinic
PreopNo
Surgery
Recovery ICUWard
Discharge
Regional
MRI
OR7
OR2
Endo
OR8
Endo
OR9
OR3 OR4OR1
OR6
SP
OR5
OR10
Endo
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“It is the responsibility of the OR directors and clinical managers to do any and all cases that can be done safely without compromising quality of care.”
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“It is also the responsibility of the OR managers to provide surgeons with open access to OR time, to maximize OR efficiency, and to reduce overall patient waiting.”
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Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
![Page 8: Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics](https://reader036.vdocuments.mx/reader036/viewer/2022062515/56649cdc5503460f949a6d85/html5/thumbnails/8.jpg)
First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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Months to years before DOS
1st stage of OR allocation
Based on financial data Allocate OR time to
increase Contribution Margin
Involves changes in OR workload over months to years.
Weeks to days before DOS
2nd stage of OR allocation
Not based on financial data
Allocate OR time to increase OR Utilization
Matches staffing to existing workload
Tactical Decisions Operational Decisions
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“In order to grow a specialty service, hospital administrators must tactically allocate more OR time by recruiting more surgeons, purchasing more equipment, expanding clinics, or increasing ward and ICU usage.”
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
![Page 14: Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics](https://reader036.vdocuments.mx/reader036/viewer/2022062515/56649cdc5503460f949a6d85/html5/thumbnails/14.jpg)
First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
![Page 15: Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics](https://reader036.vdocuments.mx/reader036/viewer/2022062515/56649cdc5503460f949a6d85/html5/thumbnails/15.jpg)
First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
![Page 16: Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics](https://reader036.vdocuments.mx/reader036/viewer/2022062515/56649cdc5503460f949a6d85/html5/thumbnails/16.jpg)
First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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1. 240 minute (4 hours)2. 720 minutes (12 hours)3. 840 minutes (14 hours)4. 1080 minutes (18 hours)
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1. 240 minute (4 hours)2. 720 minutes (12 hours)3. 840 minutes (14 hours)4. 1080 minutes (18 hours)
Explanation: On Monday, CT surgery utilized 4 hours of an 8 hour block. On Tuesday, CT surgery utilized all 8 prime time hours, plus 6 additional hours.
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1. 25%2. 50%3. 75%4. 100%
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1. 25%2. 50%3. 75%4. 100%Explanation: Although CT surgery operated for 18 hours, only 12 of those hours
were during prime-time. CT surgery was allocated 16 hours. Therefore 12/16 = 0.75 or 75%.
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OR Utilization is just one of many factors influencing OR allocation.
OR Utilization alone is poorly related to patient waiting time, variable costs, and contribution margin.
Many times, increased utilization can decrease the profit margin (over utilization) and decrease surgeon flexibility.
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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Over-utilized time (Over) – time that the OR is used and not staffed (“Overtime” = time and a half)
Under-utilized time (Under) – time that the OR is staffed and not used
Inefficiency of use of OR time (IU_OR)– the sum of the products of cost of under-utilized time multiplied by the number of under-utilized hours and the cost of over-utilized hours multiplied by the number of over-utilized hours.
IU_OR = Under + 1.5(Over)
Heavily dependent on the OR manager’s ability to minimize over-utilized time.
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1. 2 hours2. 4 hours3. 6 hours4. 8 hours
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1. 2 hours2. 4 hours3. 6 hours4. 8 hours
Explanation: 4 hours of under utilized time on Monday and 0 hours of under-utilized time on Tuesday.
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1. 2 hours2. 4 hours3. 6 hours4. 8 hours
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1. 2 hours2. 4 hours3. 6 hours4. 8 hours
Answer: 0 hours of over-utilized time on Monday and 6 hours of over-utilized time on Tuesday.
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1. 4 hours2. 8 hours3. 12 hours4. 16 hours
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1. 4 hours2. 8 hours3. 12 hours4. 16 hours
Answer: 4 + 1.5(8) = 16. Ideally you would want this number to approach zero.
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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20 minutes behind
OR 1
OR 2
60 minutes behind
What is the tardiness of OR 1?
What is the tardiness of OR 2?
5 x 20 = 100 minutes
1 x 60 = 60 minutes
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1. Patient for Room 12. Patient for Room 2
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1. Patient for Room 12. Patient for Room 2
Patient Safety – unaffected by decisionOpen Access – unaffected by decisionOR Efficiency – unaffected by decision * OR1 is expected to have 0 over utilized hours. * OR 2 is expected to have 0 over utilized hours.Patient waiting – affected by decision * OR 1 expected total tardiness of 40 minutes * OR 2 expected total tardiness of 10 minutes
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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How do I optimize Prime Time Utilization, OR Efficiency, and
Tardiness?
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
![Page 38: Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics](https://reader036.vdocuments.mx/reader036/viewer/2022062515/56649cdc5503460f949a6d85/html5/thumbnails/38.jpg)
1. OR Allocation (Staffing)2. Turnover time3. Case Duration prediction accuracy4. First case start percentage5. Clinician efficiency6. Staff assignment7. Staff scheduling
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1. OR Allocation (Staffing)2. Turnover time3. Case Duration prediction accuracy4. First case start percentage5. Clinician efficiency6. Staff assignment7. Staff scheduling
Explanation: The principal determinant of OR Efficiency is OR Allocation or Staffing. OR Efficiency applies to the existing workload.
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
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OR Allocation (Staffing)Months before DOS
Tactical decisions determine increases in OR time allocation
Operational decisions based on OR efficiency fill the OR time once the actual workload is known
Dr. Thomas underestimates case durations and operates for 12 hours a day when the OR is only staffed for 8 hours.
From an operational perspective, surgeons schedule cases on any future workday,
regardless of OR staffing.
The OR should be staffed for 12 hours for this surgeon. Over –utilized OR hours are reduced without increasing under-utilized
hours.
Every case scheduling conflict is a failure of OR allocation until proven otherwise.
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First-case start percentage
Clinician efficiency
OR efficiency
Case duration prediction accuracy
Turnover Time
Staff Assignment
OR Allocation (Staffing)
Staff Scheduling
Tardiness
Safety
Open Access
Efficiency
Patient Waiting
Professional Satisfaction
Prime Time Utilization
![Page 43: Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics](https://reader036.vdocuments.mx/reader036/viewer/2022062515/56649cdc5503460f949a6d85/html5/thumbnails/43.jpg)
First-case start percentage
Clinician efficiency
Case duration prediction accuracy
Turnover Time
“Working fast and efficiently is
always a good characteristic, but if the OR managers do not allocate OR time appropriately,
the benefits of working fast may
be negated.”
Case duration prediction accuracy is critical for matching the predicted workload to the actual workload.
Hypothetical example: Today, Dr. Lancaster had the best day of his life. He was in the OR at 7:10 for his first case, a massive oncological disaster. Fiberoptic intubation, central line, a-line, and thoracic epidural all done by 7:30. Incision at 7:31. The case is predicted to last 6 hours, followed by a 1 hour port removal (+1 hour turnover time). The first case finishes 2 hours before the predicted case duration, and Dr. Mehl turns over the OR himself in 15 minutes. Because of Dr. Mehl’s awesomeness, the room finishes all of its cases 3 hours
earlier than expected. From an operational perspective, did Dr. Mehl improve OR efficiency?
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Wednesday 3/7/12
78910111213141516171819202122
4 5 6 7 8 9 10 14 17 18 E1 E2 G/S/M
10+2
6
4
0
11 over5 under + (1.75) x = 24.25 inefficiency of use of OR time
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Predicted Scheduled WorkloadThursday 3/8/12
78910111213141516171819202122
4 8 9 10 14 17 18 G1 Sp E2 E1 X X
25 under
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Predicted Scheduled WorkloadThursday 3/8/12
78910111213141516171819202122
4 8 9 10 14 17 18 G1 Sp E2 E1 X X
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OR Allocation (Staffing)Thursday 3/8/12
78910111213141516171819202122
4 8 9 10 14 17 18 G1 Sp E2 E1
25 under + + (1.75) x = Inefficiency of use of OR Time
? over
Caloia7A-7PCall
Rosen7A-3P
Martin
11-7P
BatesRes.
MehlRes.
LancRes.
WeissRes.
Worle11-7P
Boudr7A-3P
St. Joh
7A-3P
Rex7A-3P
Train7A-5P
Badon
7A-3P
Palme7A-3P
Train7A-5P
Guilb7A-3P
Casey7A-3P
Guilb7A-3P
19 under
Murra7A-3P
Baker7A-3P
X2 X5
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PTU based on Allocated OR TimeThursday 3/8/12
78910111213141516171819202122
4 8 9 10 14 17 18 G1 Sp E2 E1 2 5
#4FriedMetz Block
4 of 8
50% PTU
#8FCFS Block
6 of 8
75% PTU
#12FCFSBlock
8 of 8
100%PTU
#10ACS
McGin Block
8of 8
100% PTU
#14U/E
Block
#17Kandil Block
8 of 8
100% PTU
#18Lee
FCFSBlock
4 of 8
50% PTU
#15CV
Releas
0 of 8
0% PTU
OSL#2
Bellow
Block
0 of 8
0% PTU
#5Hellst
rBlock
0 of 8
0% PTU
OSL
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Stat YTD Avg Target HCA Average
1st Case on time starts
68% 90% 56%
Scheduled Duration Accuracy
38% 90% 59%
On time starts 52% 90% 53%
Prime Time Utilization
73% 75% 49%
Average Physician TAT
47 min <35 min Unknown
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Surgeons are responsible for scheduling cases into block time and accurately estimating case duration.
OR Managers are responsible for allocating OR time to match the workload.
Departmental Conference Friday Morning Two to One Resident Supervision Resident Didactics on Thursday Afternoon
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OR Allocation is based on both Tactical and Operational decisions. Tactical decisions are made by hospital administrators and use
financial metrics such as contribution margin per OR hour to increase total OR allocation.
Tactical decisions increase allocation by increasing workload. A doctor with low utilization may get more OR time allocated by
administrators if he/she has a very high CM/OR hour. Operational decisions adjust allocation to the existing workload to
optimize OR efficiency. OR allocation (staffing) has the greatest impact on OR efficiency. Prime time utilization is a useful indicator, but must be interpreted in
conjunction with other metrics. Turnover time, case duration prediction accuracy, and clinician
efficiency improve OR efficiency only if OR allocation is appropriate. Operational decisions should always follow the ordered priorities
1. If the case can be done safely, it should be done.2. Surgeons should have open access to OR time. Scheduling conflicts are a result of improper
OR allocation until proven otherwise. 3. Operational decisions should minimize Inefficiency of use of OR time, which is heavily
dependent on Over-utilized time. 4. Operational decisions should minimize overall tardiness. Case duration prediction accuracy,
turnover time, and clinician efficiency can reduce variability responsible for increasing tardiness.
5. Physician satisfaction should only be considered after all other ordered priorities are satisfied. This relates to calling in teams to finish the day because of personal obligations, etc.